meme kanserİankaratipdahiliye.org/pdf/yuksel1.pdf · 2020-03-31 · meme kanseri ilişkili...
TRANSCRIPT
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MEME KANSERİ
Dr. Yüksel ÜRÜN
@DrYukselUrun
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Epidemiyoloji Kadınlarda:
En sık görülen kanserdir.
Her üç veya dört kanserden biri
Globocan verilerine göre yıllık 2 M’a
Ülkemizde yüz binde 46
Taramanın yaygınlaşması, tedavi ile ilgili gelişmeler sonucunda
meme kanseri ilişkili mortalite azalmaktadır.
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J Clin Oncol 37:834-849.
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J Clin Oncol 37:834-849.
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J Clin Oncol 37:834-849.
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•MÖ 550 – 475•I.Darius’un Eşi•Democedes
Atossa
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19060
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1 Saatte190 yeni vaka
60 ölüm
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http://kanser.gov.tr/Dosya/ca_istatistik/ANA_rapor_2013v01_2.pdf
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CA CANCER J CLIN 2018;0:1–31
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CA CANCER J CLIN 2018;0:1–31
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CA CANCER J CLIN 2018;0:1–31
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0
10
20
30
40
50
60
70
80
90
100
Lokal evre Bölgesel yayılım uzak metastaz Belirsiz evre
5 yıllık GSK
5 yıllık GSK
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Hastaların önemli bir
kısmında etyoloji
bilinmemektedir.
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Kuvvetli risk faktörleri
Yaş
Cinsiyet: Tüm kadınlar risk altında!!! BRCA1 – BRCA2 mutasyonu
Aile öyküsü 1.derece
Erken yaş
Atipik hiperplazi
RT
Kanser öyküsü
Yüksek meme dansitesi
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YAŞ 10 yıllık RİSK
30 . . ….... . . . 0,44 (1 /227)
40 . . …...... . . . 1,47 (1 /68)
50 . . …...... . . . 2,38 (1 /42)
60 . . …...... . . . 3,56 (1 /28)
70 . . . …...... . . 3,82 (1 /26)
Yaşam boyu risk………… 12 (1/8)
http://www.cancer.gov/types/breast/risk-fact-sheet
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2001 2007: 56 y
Risk MEME OVER
Normal %12 %1,3
BRCA1 %55-65 %39
BRCA2 %45 %11-17
Am J Hum Genet. 2003 May;72(5):1117-30
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Herediter meme kanserleri
Meme kanserlerinin %5-10’u
BRCA1 %20-40
BRCA2 %10-30
TP53 <%1
PTEN <%1
Bilinmeyen %30-70
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Zayıf-orta risk faktörleri
Aile öyküsü:ileri yaş
<12 yaş menarş
>55 yaş menopoz
Nulliparite
>35 yaş sonrası ilk
doğum
HRT (E+P)/OKS
Postmenopozal kilo
artışı
Sedanter yaşam
Alkol: 2-3 ölçü/gün:
%20 risk artışı
Batı tipi diyet
Çevresel toksinler
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Tartışmalı – Yanlış olduğu düşünülenfaktörler
D/C – Düşük
Sutyen
Meme implantları
Kafein
Cep telefonu
Deodorant-antiperspirant
Saç boyama ???
Solak olma
Migren
Meme travması
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Tarama ve önleme
Tarama
Kemoprevansiyon
Cerrahi prevansiyon
Yaşam tarzı değişiklikleri
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MEME KANSERİ TARAMA PROGRAMI ULUSAL STANDARTLARI
40-69 yaş
Mammografi
2 yılda bir
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Belirti ve bulgular
31
En sık: kitle veya kalınlaşma, sıklıkla ağrısız
areola renk ve görünümünde değişiklik
Kızarıklık, portakal kabuğu görünümü
akıntı veya kanama
Meme boyut ve konturlarında değişiklik
Meme başı çekintisi
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Hormon reseptörleri
%65-75 hastada pozitif: Endokrin tedaviye
aday
ER: östrojen resptörü
PR: progesteron resptörü
%25 hormon reseptörü negatif
ONCOLOGY LETTERS 9: 1207-1212, 2015
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ONCOLOGY LETTERS 9: 1207-1212, 2015
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Human epidermal growth factor receptor-2
• c-erbB-2; Her2/neu; HER-2; HER-2/neu
• Transmembran tirozin kinaz reseptörü
IHC
0 veya 1+ : Negatif
2+ ek test gerekir (FISH/CISH)
3+: Pozitif
%15-25 hastada pozitif: anti-HER2 tedaviye aday
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The American Journal of Pathology, Vol. 183, No. 4,
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Sorlie T. PNAS, 2001
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JAMA. 2019;321(3):288-300. doi:10.1001/jama.2018.19323
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TedaviKüratif
Palyatif
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Cerrahi
Radikal mastektomi
Meme, pektoral kas, aksiller LN
Modifiye radikal mastektomi
Meme, pektoral kas fasyası, aksiller LN
Meme koruyucu cerrahi
Sentinel lenf nodu biyopsisi
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Adjuvant tedaviler
Amaç: nükslerden sorumlu olan
mikrometastazların ortadan kaldırılması
Hormonal tedavi
Kemoterapi
Hedefe yönelik tedavi
Radyoterapi
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Hormon reseptör pozitifliği
5 yıl tamoksifen ile
Nüks riskinde ≈ %50
Ölüm riskinde %35
Aromataz inhibitörleri
Postmenopozal kadınlarda
≥Tamoksifen!!!
JAMA. 2019;321(3):288-300. doi:10.1001/jama.2018.19323
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Kemoterapi
Antrasiklin temelli tedaviler
Doksorubisin veya epirubisin ve siklofosfamid
Kardiyotoksisite!!!
Taksanlar
Paklitaksel veya docetaksel
Trastuzumab
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Herkese adjuvan tedavi vermeli miyiz?
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N Engl J Med 2018;379:111-21.
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N Engl J Med 2018;379:111-21.
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N Engl J Med 2018;379:111-21.
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Evre IV – Metastatik Meme Kanseri
Amaç:
Aşırı toksisiteye neden olmadan semptomların
önlenmesi veya giderilmesi
Sağkalımda iyileşme
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Metastatik hastalıkta tedavi
Lokal tedaviler
Cerrahi
RT
Endokrin tedaviler
Kemoterapi
Hedefe yönelik tedaviler
Trastuzumab
Lapatinib
Pertuzumab
T-DM1 (trastuzumab
emtansine)
PARP inhibitörleri
Kemik modifiye edici ajanlar
Bisfosfonatlar
Denosumab
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Metastatik hastalıkta endokrin tedavi
Aromataz inhibitörleri (anastrazol, letrozozol,
ekzemestan)
Tamoksifen
Fulvestrant
CDK4/6 inhibitörleri (Palbociclib, ribociclib,
abemaciclib)
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Ribociclib
Abemaciclib
Palbociclib
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Anti-HER2 tedaviler
Lancet 2017; 389: 2415–29
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Cancer 2018;00:00-00. American Cancer Society.
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HER2CLIMB: Phase III Study Design
Randomized, double-blind, placebo-controlled, active comparator phase III trial at 155 sites in 15 countries (February 2016 to May 2019); data cutoff: September 4, 2019; median f/u: 14.0 mos
Patients with HER2+ MBC; prior trastuzumab, pertuzumab,
and T-DM1; ECOG PS 0-1; brain mets allowed*
(N = 612)
Tucatinib 300 mg PO BID +Trastuzumab 6 mg/kg Q3W (loading dose: 8 mg/kg C1D1) +
Capecitabine 1000 mg/m2 PO BID, D1-14(n = 410)
Placebo PO BID +Trastuzumab 6 mg/kg Q3W (loading dose: 8 mg/kg C1D1) +
Capecitabine 1000 mg/m2 PO BID, D1-14(n = 202)
*Including previously treated stable mets, untreated mets not needing immediate local therapy, and previously treated progressing metsnot needing immediate local therapy.
21-day cyclesStratified by brain mets (yes vs no), ECOG PS (0 vs 1), and region (US or Canada vs rest of world)
Murthy. SABCS 2019. Abstr GS1-01. Murthy. NEJM. 2019;[E-pub]. Slide credit: clinicaloptions.com
Primary endpoint: PFS (RECIST v 1.1 by BICR) among first 480 randomized patients
‒ 90% power with 288 events at α = 5%, HR: 0.67
Secondary endpoints (total population): OS, PFS in patients w/ brain mets, ORR in patients w/ measurable disease, safety in patients who received ≥ 1 dose of study tx
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46.3
HER2CLIMB: PFS (Primary Endpoint Population)
Murthy. SABCS 2019. Abstr GS1-01. Murthy. NEJM. 2019;[E-pub]. Slide credit: clinicaloptions.com
Events, n/N
7.8 (7.5-9.6)5.6 (4.2-7.1)
Median PFS, Mos (95% CI)
Tucatinib + Trastuzumab/CapePlacebo + Trastuzumab/Cape
178/32097/160
33 (27-40)12 (8-21)
1-Yr PFS, % (95% CI)
46% reduction in risk of disease progression
HR: 0.54 (95% CI: 0.42-0.71; P < .00001)
100
80
60
40
20
00 3 6 9 12 15 18 21 24 27 30 33 36
Pat
ien
ts A
live
and
Fre
e fr
om
Dis
ease
Pro
gres
sio
n (
%)
Mos Since RandomizationPatientsat Risk, n
Tucatinib ArmPlacebo Arm
320160
23594
15245
9827
406
294
152
101
81
40
20
10
00
62.9
12.3
33.1
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26.6
HER2CLIMB: OS (Total Population)
Murthy. SABCS 2019. Abstr GS1-01. Murthy. NEJM. 2019;[E-pub]. Slide credit: clinicaloptions.com
21.9 (18.3-31.0)17.4 (13.6-19.9)
Median OS, Mos (95% CI)
Tucatinib + Trastuzumab/CapePlacebo + Trastuzumab/Cape
130/41085/202
45 (37-53)27 (16-39)
2-Yr OS, % (95% CI)
HR: 0.66 (95% CI: 0.50-0.88); P = .0048)
34% reduction in risk of death
Events, n/N100
80
60
40
20
00 3 6 9 12 15 18 21 24 27 30 33 36
Pat
ien
ts A
live
(%)
Mos Since Randomization
410202
388191
322160
245119
17877
12348
8032
5119
347
205
102
41
00
44.9
75.5
62.4
Patientsat Risk, n
Tucatinib ArmPlacebo Arm
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HER2CLIMB: PFS in Patients With Brain Metastases (Total Population)
Murthy. SABCS 2019. Abstr GS1-01. Murthy. NEJM. 2019;[E-pub]. Slide credit: clinicaloptions.com
Events, n/N
7.6 (6.2-9.5)5.4 (4.1-5.7)
Median PFS, Mos (95% CI)
Tucatinib + Trastuzumab/CapePlacebo + Trastuzumab/Cape
106/19851/93
25 (17-34)0
1-Yr PFS, % (95% CI)
52% reduction in risk of disease progression
HR: 0.48 (95% CI: 0.34-0.69; P < .00001)
100
80
60
40
20
00 3 6 9 12 15 18 21 24 27 30 33 36
Pat
ien
ts A
live
and
Fre
e fr
om
Dis
ease
Pro
gres
sio
n (
%)
Mos Since Randomization
19893
14449
7812
454
140
80
20
10
10
10
10
10
00
60.4
33.9
0
24.9
Patientsat Risk, n
Tucatinib ArmPlacebo Arm
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DESTINY-Breast01: Baseline Characteristics
Krop. SABCS 2019. Abstr GS1-03. Modi. NEJM. 2019:[Epub]. Slide credit: clinicaloptions.com
CharacteristicT-DXd 5.4 mg/kg
(N = 184)
Median age, yrs (range) 55 (28-96)
Female, % 100
Region, % Asia N. America Europe
34.228.837.0
ECOG PS, % 0/1 2
55.4/44.00.5
Hormone receptor status, % Positive Negative Unknown
52.745.12.2
CharacteristicT-DXd 5.4 mg/kg
(N = 184)
Median prior lines of treatment, n (range) Trastuzumab, % T-DM1, % Pertuzumab, % Other anti-HER2 therapy, % Hormone therapy, % Other systemic therapy, %
6 (2-27)10010065.854.348.999.5
Visceral disease, % 91.8
History of brain metastases, % 13.0
HER2 expression, % IHC 3+ IHC 2+, ISH+ IHC 1+, ISH+
83.715.21.1
T-DXd, trastuzumab deruxtecan.
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DESTINY-Breast01: Response (ITT)
Krop. SABCS 2019. Abstr GS1-03. Modi. NEJM. 2019:[Epub]. Slide credit: clinicaloptions.com
Response (ITT) T-DXd 5.4 mg/kg (N = 184)
ORR* (by ICR; n = 112), % (95% CI) 60.9 (53.4-68.0)
CR (n = 11) 6.0
PR (n = 101) 54.9
SD (n = 67) 36.4
PD (n = 3) 1.6
Not evaluable (n = 2) 1.1
DCR, % (95% CI) 97.3 (93.8-99.1)
6-mo CBR, % (95% CI) 76.1 (69.3-82.1)
Median DoR, mos (95% CI) 14.8 (13.8-16.9)
Median time to response, mos (95% CI) 1.6 (1.4-2.6)
*Primary endpoint.
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DESTINY-Breast01: Best Change in Tumor Size
Krop. SABCS 2019. Abstr GS1-03. Modi. NEJM. 2019:[Epub]. Slide credit: clinicaloptions.com
Patients (N = 168)
Bes
t P
erce
nta
ge C
han
ge F
rom
B
asel
ine
in S
um
of
Dia
met
ers
100
80
60
40
20
0
-100
-80
-60
-40
-20
Confirmed ORR: 60.9% (95% CI: 53.4-68.0); 11 CRs
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DESTINY-Breast01: PFS
Krop. SABCS 2019. Abstr GS1-03. Modi. NEJM. 2019:[Epub]. Slide credit: clinicaloptions.com
Median PFS: 16.4 mos (95% CI: 12.7-NR)
Median PFS in 24 patients with brain mets: 18.1 mos (95% CI: 6.7-18.1)
Censored: 68.5%
Events: 31.5%
Median follow-up: 11.1 mos (range: 0.7-19.9)
Pro
bab
ility
of
PFS
MosPatients at Risk, n 184 182 174 155 153 135 121 107 103 94 69 54 38 17 11 10 9 4 3 1 0
1.0
0.8
0.6
0.4
0.2
0.00 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
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10
DESTINY-Breast01: OS
Krop. SABCS 2019. Abstr GS1-03. Modi. NEJM. 2019:[Epub]. Slide credit: clinicaloptions.com
Median OS: NR
Censored: 86.4%
Events: 13.6%
Median follow-up: 11.1 mos (range: 0.7-19.9)
Pro
bab
ility
of
OS
Patients at Risk, n 184 183 182 179 174 171 167 161 155 147 133 101 66 36 21 16 12 9 8 4 0
1.0
0.8
0.6
0.4
0.2
0.00 1 2 3 4 5 6 7 8 9 11 12 13 14 15 16 17 18 19 20
Mos
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Anti-HER2 tedaviler
Lancet 2017; 389: 2415–29
Trastuzumab Lapatinib Pertuzumab TrastuzumabEmtansin
Neratinib
Sınıf Monoklonalantikor
Tirozin kinazinhibitörü
Monoklonalantikor
Antikor-ilaçkonjugatı
Tirozin kinazinhibitörü
EtkiMekanizması
Rekombinant,hümanize, MAB, ligand bağımsızHER2 ve HER3 sinyal iletimini
inhibe eder.
HER2 dual tirozinkinaz inhibitörü
Ligand bağımlıHER2
dimerizasyonunuengeller
Maytansinderivesi potent
mikrobülinhibtörü vetrastuzumabkonjugasyonu
HER1, HER2 veHER4 tirozin
kinaz inhibitörü
Endikasyonu HER2 pozitiferken evre
meme kanseri, metastatik
meme kanseri
HER2 pozitifmetastatik
meme kanseri
HER2 pozitifinoperabıl
meme kanseri
HER2 pozitifmetastatik
meme kanseri
HER2 pozitiferken evre
meme kanseri, metastatik
meme kanseri
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2010 a kadar immünoterapi :(
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IMpassion130: Study Design
Patients with metastatic or inoperable, locally advanced TNBC; no prior therapy for
advanced setting (prior RT or CT in curative setting allowed
if ≥ 12-mo DFI); RECIST v1.1 measurable
disease; ECOG PS 0/1;
tumor evaluable for PD-L1*(N = 902)
Treatment until PD per RECIST v1.1
or intolerable toxicity
No crossover Allowed
Survival follow-up
Atezolizumab 840 mg IV Q2W +nab-Paclitaxel 100 mg/m2 IV on D1, 8, 15
28-day cycles(n = 451)
Placebo IV Q2W +nab-Paclitaxel 100 mg/m2 IV on D1, 8, 15
28-day cycles(n = 451)
Slide credit: clinicaloptions.comSchmid. ASCO 2019. Abstr 1003. Schmid. NEJM. 2018;379:2108.
Randomized, double-blind, placebo-controlled phase III trial
Coprimary endpoints: PFS and OS (ITT population and PD-L1+ subgroup)
— Prespecified hierarchical OS testing in ITT population; if significant, then PD-L1+ population
Stratified by prior taxane use in curative setting (yes vs no), liver metastases (yes vs no), PD-L1 IC status (≥ 1% vs < 1%)
*By prospective central testing with SP142 PD-L1 IHC assay.41% of patients in each arm were PD-L1+ (≥ 1 % IC).
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IMpassion130 Update: OS by PD-L1 Status
Schmid. ASCO 2019. Abstr 1003. Slide credit: clinicaloptions.com
Median OS, Mos HR (95% CI)
Atezolizumab+ nab-Paclitaxel
Placebo+ nab-Paclitaxel
PD-L1+ 25.0 18.0 0.71 (0.54-0.93)
PD-L1– 19.7 19.6 0.97 (0.78-1.20)
Treatment benefit limited to PD-L1+ tumors
Atezo + nab-Pac (PD-L1+, n = 185)Pbo + nab-Pac (PD-L1+, n = 184)Atezo + nab-Pac (PD-L1–, n = 266)Pbo + nab-Pac (PD-L1–, n = 267)
100
80
60
40
20
0
OS
(%)
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42Mos
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